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C O M M E N T A R Y Open Access
Retinal involvement in sepsis: from the eye
of the patient to the eye of the beholder
E. Christiaan Boerma
See related research by Erikson et al., https://ccforum.biomedcentral.com/articles/10.1186/s13054-017-1676-3
Keywords: Sepsis, Fluorescence angiography, Retinal blood flow, Roth spot
In the history of mankind the importance of the eye has
always extended beyond the organ itself. In ancient
Egypt the “Eye of Horus”represented royal power and
good health and reflected all six senses. In Greek myth-
ology the symbolic value of the eye was already sup-
ported by detailed medical knowledge [1]. Not only
symbolizing the giant one-eyed cyclops’limited
intelligence in contrast to the vigilance of Panoptes,
whose body was covered by eye’s, the stories also
reflected the understanding of the concepts of visual
fields and acuity. In modern ophthalmology the idea of
ocular involvement in systemic diseases, such as lupus
and diabetes, is well established. In addition, the eye is
also known as an organ that “mirrors”diseases in a dis-
tant primary organ of interest; Roth spots in endocarditis
is the classic example [2].
In a recently published paper in Critical Care Erikson
and co-workers extended these ideas to the context of
sepsis [3]. They added direct observation of the retina to
the already many-headed sepsis Hydra, which affects so
many organs. Retinal fluorescein angiography was per-
formed twice during the first 5 days in the intensive care
unit in 31 patients with sepsis. In addition ocular pres-
sure was determined. By doing so the authors demon-
strated the feasibility of this technique in the local ICU
setting, despite practical limitations. And the results
were alarming. More than half of the patients displayed
signs of retinal pathology, including fluorescein-leaking
retinal micro-aneurysms, vitreous hemorrhages, and
other retinal hemorrhages. These findings were bilateral
in 75% of the affected cases. Ocular hypertension was
present in 16% of all septic patients.
Such abnormalities were increasingly present in the
subgroup of septic patients with a slowdown of arterial
retinal blood flow, expressed as a prolonged retinal
arterial filling time >8.3 s. In general these patients were
sicker and had lower cardiac output. This led the
authors to believe that retinal fluorescein angiography
has potential to detect and characterize sepsis in a non-
invasive way (with the exception of an intravenous fluor-
escent dye, that is). But as tempting as it may seem, such
a search for the holy grail of an easily accessible organ
that “represents”(all) other organs carries the risk of
oversimplification. Recent examples of tonometry as a
“canary of the body”and the sublingual microcirculation
as a window for other organs remind us to be cautious
[4, 5], especially in a disease state that is characterized
by heterogeneity of blood flow within and between
organs [6]. In addition, the idea to use retinal micro-
vascular blood flow as a surrogate for intracranial
perfusion is equally tempting. Previous observations
have suggested that both retinal and conjunctival blood
flow may, to some extent, represent cerebral blood flow
changes during carotid endarterectomy [7, 8]. Others
observed that retinal blood flow may reflect intracranial
hypertension [9]. However, the absence of abolishment
of conjunctival blood flow during angiography-proven
brain death is reason to use the eye as a window for the
brain with great caution [10].
Where should we go from here? Irrespective of the
issue of retinal pathology as a surrogate for the effects of
sepsis in other organs, what is the relevance of the find-
ings in themselves. If more than half of sepsis patients
have retinal pathology, what are the clinical conse-
quences? Are they related to visual outcome? And do
they need follow-up? The fact that, in this study, the
abnormal retinal findings had resolved in a control
Correspondence: e.boerma@chello.nl
Department of Intensive Care, Medical Centre Leeuwarden, Leeuwarden, The
Netherlands
© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Boerma Critical Care (2017) 21:148
DOI 10.1186/s13054-017-1721-2
angiography 3–6 months after hospital discharge in sur-
viving patients is seemingly reassuring, but these need to
be confirmed in larger high-risk patient cohorts. In
addition it is known that processes other than sepsis,
such as hypoxia or ischemia, may also upset the normal
retina–blood barrier in the retinal capillaries, thereby
allowing extravascular leakage of fluorescein. This war-
rants further studies to establish the incidence of retinal
pathology in other high-risk ICU populations. And what
about post-ICU check-ups for intraocular hypertension,
usually unnoticed by the patient until irreversible visual
damage has occurred. With an increasing ICU survival
rate even for very complicated disease states such as
sepsis, the ICU community is becoming more and more
aware of post-ICU sequelae, also referred to as post-
intensive care syndrome (PICS) [11]. In addition to ICU-
acquired weakness and cognitive impairment, even a
small deterioration in visual abilities may be very rele-
vant for daily life activities, especially in the frail elderly
with a pre-existing decline in function of potentially all
six senses prior to and after ICU admission [12].
We thank doctor Erikson and his colleagues for their
effort to cross the (imaginary) border between the ICU
and the ophthalmology department. Their innovative
research has made the ICU community aware of the fact
that sepsis, and potentially other critically ill disease
states, may affect the eyes of ICU patients. Undoubtedly
this will change the eye of the beholder as well.
Acknowledgements
None.
Funding
None.
Availability of data and materials
Not applicable.
Authors’contributions
ECB wrote the commentary and read and approved the final version.
Authors’information
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Consent for publication
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Ethics approval and consent to participate
Not applicable.
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Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
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